Provider Demographics
NPI:1972280816
Name:GREEN, LILLY KAYA KYARTHWYN
Entity Type:Individual
Prefix:MS
First Name:LILLY KAYA
Middle Name:KYARTHWYN
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LILLY KAYA
Other - Middle Name:KYARTHWYN
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:12409 HARDIN CT NE APT D
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2791
Mailing Address - Country:US
Mailing Address - Phone:505-913-1470
Mailing Address - Fax:
Practice Address - Street 1:12409 HARDIN CT NE APT D
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2791
Practice Address - Country:US
Practice Address - Phone:505-913-1470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM61512363LF0000X, 390200000X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily